Deirdre Bonnycastle's Blog on Teaching in Medicine

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Monthly Archives: May 2006

Dr. Michael Hebert from http://www.drhebert.squarespace.com/ talks about Medical Education
This past weekend at the Jazz Fest in New Orleans, I dropped in at the Gospel tent to listen to Sherman Washington and the Zion Harmonizers. The Zion Harmonizers are a longtime Jazz Fest staple, having performed in the Fest every year since its inception over 30 years ago. They have been a driving force in the New Orleans Gospel music community for 67 years.
Sherman Washington, its leader, joined in 1942. He was recruited by a Harmonizer at work while building Higgins assault boats in a New Orleans shipyard for the U.S. Navy during World War II . He became the group manager in 1948, and has been its organizer and spokeman ever since.
Mr. Washington took the stage first and introduced the band. A chair was brought out for him, and he sat down just left of center stage. From there the younger guys took over. An octogenarian who had recently suffered a small stroke, Mr. Washington was passing the torch to his protégés and remained onstage as the moral leader. Like any member of the crowd, he watched, clapped, tapped his feet, and joined in when the spirit moved him.
The spirit came. Working the crowd like any veteran performance group, the Harmonizers started off slow and built up energy with each successive song. A half-an-hour deep and the joint was jumping. Folks danced in the aisles, feet stomped, hands waved in the air, and the very ground moved beneath us. If the Gospel tent wasn’t sacred ground before, the Harmonizers consecrated it.
It is remarkable that any single group could lead the New Orleans Gospel community for 67 years running. To maintain its vigor, the group is constantly bringing in new voices as the older ones retire. This is not the same Zion Harmonizers that Sherman Washington joined in 1942. And yet, if I closed my eyes and listened to the Harmonizers in 2005 and a recording of the 1942 group that recruited Sherman Washington, I don’t think I would detect much of a difference.
If a group that is 67 years old and going strong has anything on its side, it has time. Time to carefully cull prospective members from the community. Time to bring them in and teach them right. Time to bond with them as family, and then inculcate every little nuance about Gospel music, Harmonizer style. With this educational process going on, very little will be lost over the generations. The Zion Harmonizer sound becomes the constant, a spirit that exists independently of its members.
The Harmonizers represent one of two strategies for learning. Their model, the apprenticeship, passes knowledge from one generation to another through close, personal instruction. Before one member, such as Sherman Washington, moves on, a new member is picked out and the elder’s knowledge is passed on as intact as possible to the new member. Just as wine takes the shape of each successive cup it is poured into, the art takes the shape of the new vessel as it is passed on, but it still retains its original flavor.
The alternative to the apprenticeship strategy is education by committee. With this approach the learner moves from expert to expert, never exclusively the student of a single person, gleaning from each teacher that bit of information the expert knows best. Medical education is by committee. The typical medical student moves from one specialty to another, from cardiology to neurosurgery to dermatology, learning the best each specialist has to offer. The thinking behind this approach is that the student picks up a little of the best of everything, and cobbles together an overall education that represents the highlights of the best; in theory, a better overall education than any single teacher can give.
There are problems with education by committee. Each teacher has his own bias, and the sum of all biases many not amount to anything meaningful. For example, a pediatrican may teach a student his love for child advocacy, and a surgeon may teach the pleasure of curing a patient through the corporal handiwork of cutting and suturing. But these two biases are different, and not necessarily complimentary. The student has no overarching philosophy offered to him by any single individual. He is left with a hodgepodge of ideas that he has to organize himself.
Like every medical student I knew, I had to make sense of medicine on my own. Knowledge was meted out to me like precious jewels, but when I completed my training all I had was a bag of gems. No organization or sense of relative value, and certainly no sense of how I was to use them. In medical school, we used to call useful clinical tips pearls. So even in our doctor’s language we were acknowledging an essential fact about our education. We had precious knowledge doled out to us bit by bit, but stringing the pearls into something of real purpose left up to us.
It was rare that a concerned teacher checked to see if we were coming up with anything. The closest I usually got was the question, “So what do you think you will specialize in?” This question often started with the casual word so, which to me was a way of saying, “I am interested in where you are going with this education you are getting, but I am probably not going to be able to help you with it.” (The underground advice in med school was that you always told the professor you were interested in going into his specialty. That way he would take an interest in teaching you. If you said you were interested in a different specialty there was a very real risk that the professor would lose interest in teaching you any more than nuts and bolts. Thus once again we students instinctively understood and tried to cope with the weakness in the committee education.)
Of course, the apprenticeship model is not perfect either. When a student learns everything the preceptor knows, he learns his teacher’s foibles as well. No one person can know everything there is to know, so a teacher’s deficiencies became a student’s deficiencies. A good preceptor should recognize his own weaknesses and send the student to other experts to supplement his knowledge. But this does not always happen. The old adage that the student can never surpass his master is rooted in the apprenticeship model.
Certainly the two approaches can co-exist. An education by committee can include a handpicked mentor who guides the student through the learning stages. An apprenticeship can be enhanced by brief training periods under other teachers. But to me, the two models are not equal choices. Committee education is cheaper and quicker, and works well when the goal is to cram a lot of information into the learner’s mind in a short period of time. A seminar, for instance. But committee education is clearly information-oriented, and not very humanistic.
Any time the goal is to instill humanity and passion, the apprentice model has to predominate. We learn our most essential lessons in life not by imbibing information but through observation and imitation. Most of us could do much worse than to pick the most admirable person we know and emulate him or her to the best of our abilities.
That is why it is perplexing that medicine, one of the most humanistic of sciences, leans so far towards education by committee. Our medical schools gulp up applicants in boluses of 100 to 200 and run them through the same paces, the same tests, the same clinical rotations, year after year. A surgeon and a psychiatrist get almost exactly the same medical education.
Older doctors wonder why the younger generation seems to treat medicine as a job rather than as a vocation. Young docs want paid vacation, retirement plans, and insurance benefits. When the clock strikes five they are out the door, and don’t call me at home. What happened to the days of yore when the doctor was a devoted, tireless pillar of the community?
Many things changed, but not the least of them is medical education. As the amount of information doctors needed to learn grew and grew, medical schools and residency programs gave up on the apprenticeship model and set up information assembly lines. Professors at my medical school used to gripe: “All they want is to be spoon-fed the information on the test.” To which I would answer (though not to their faces because I needed a good grade): “Then why don’t you stop reading off your lecture notes and talk to us once in a while?”
Without mentors, we dealt with the onslaught of data the best we could. We memorized it and regurgitated it on the test. Then we moved on to the next teacher, just as we were supposed to.
It was not always thus. The history of medicine is rich with preceptor-apprentice relationships. At one time, this was the expected method of medical education. The Oath of Hippocrates, written 2,400 years ago, gives more than a passing nod to apprenticeship:
I swear . . . . To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; To look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction.
In my years of medical training I can think of a few teachers that I cared about, but none that approach this degree of intimacy. I believe most physicians educated in today’s schools would say the same.
That is why I saw something very touching in the Zion Harmonizers’s performance. They brought out their leader, Sherman Washington, and placed him in an honored place on the stage even if he was not going to sing with them. All the younger Harmonizers had worked with Washington for years, learned his craft, and now felt his spirit within them. The Zion Harmonizers will live on after Sherman Washington is gone, unbowed, true to their original mission, because he took the time to teach them how to do it the right way and cared enough to make sure they understood his passion.
Medicine, which has depended on humanism for more than two millennia, could lose its original spirit in a few generations if doctors go from being teachers and guides to being service providers and HMO contractors.
Critics of modern medicine have wondered if doctors can in most cases be replaced with computers. The patient would enter some personal data and answer a few questions, then press a button, and out the diagnosis would come. I think if medical education does not go back to the apprentice model, in which values and personal insight replace massive data transfer, the doctor-computer is a certainty.
It is one thing to carry around a lot of data. It is another to carry the knowledge and the passion of your teachers, a desire to live out the ethical and personal vision of your forebears and then transfer it to the next generation, wholly intact.
Listen to what the Zion Harmonizers have to say about that. I did. I am a convert.